ARE MANUAL THERAPIES, PASSIVE PHYSICAL MODALITIES, OR ACUPUNCTURE EFFECTIVE FOR THE MANAGEMENT OF PATIENTS WITH WHIPLASH-ASSOCIATED DISORDERS
 
   

Are Manual Therapies, Passive Physical Modalities, or Acupuncture
Effective for the Management of Patients with Whiplash-associated
Disorders or Neck Pain and Associated Disorders? An Update of the
Bone and Joint Decade Task Force on Neck Pain and Its Associated
Disorders by the OPTIMa Collaboration

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   Spine J. 2016 (Dec);   16 (12):   1598-1630 ~ FULL TEXT

Jessica J. Wong, BSc, DC, FCCS(C); Heather M. Shearer, DC, MSc, FCCS(C); Silvano Mior, DC, PhD; Craig Jacobs, BFA, DC, MSc, FCCS(C); Pierre Côté, DC, PhD; Kristi Randhawa, BHSc, MPH; Hainan Yu, MBBS, MSc; Danielle Southerst, BScH, DC, FCCS(C); Sharanya Varatharajan, BSc, MSc; Deborah Sutton, BScOT, MEd, MSc; Gabrielle van der Velde, DC, PhD; Linda J. Carroll, PhD; Arthur Ameis, FRCPC, DESS, FAAPM&R; Carlo Ammendolia, DC, PhD; Robert Brison, MD, MPH; Margareta Nordin, Dr. Med. Sci.; Maja Stupar, DC, PhD; Anne Taylor-Vaisey, MLS

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation,
University of Ontario Institute of Technology (UOIT) and
Canadian Memorial Chiropractic College (CMCC);
Department of Graduate Studies,
Canadian Memorial Chiropractic College.
jessica.wong@uoit.ca


BACKGROUND CONTEXT:   In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD).

PURPOSE:   This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD.

STUDY DESIGN/SETTING:   This is a systematic review and best evidence synthesis.

SAMPLE:   The sample includes randomized controlled trials, cohort studies, and case-control studies comparing manual therapies, passive physical modalities, or acupuncture with other interventions, placebo or sham, or no intervention.

OUTCOME MEASURES:   The outcome measures were self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events.

METHODS:   We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory vs. evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance.

RESULTS:   We screened 8,551 citations, and 38 studies were relevant and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that (1) for recent but not persistent NAD grades I-II, thoracic manipulation offers short-term benefits; (2) for persistent NAD grades I-II, technical parameters of cervical mobilization (eg, direction or site of manual contact) do not impact outcomes, whereas one session of cervical manipulation is similar to Kinesio Taping; and (3) for NAD grades I-II, strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that (1) for recent NAD grades I-II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises, and Swedish or clinical massage adds benefit to self-care advice; (2) for persistent NAD grades I-II, home-based cupping massage has similar outcomes to home-based muscle relaxation, low-level laser therapy (LLLT) does not offer benefits, Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture, and needle acupuncture provides similar outcomes to sham-penetrating acupuncture; (3) for WAD grades I-II, needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and (4) for recent NAD grades III, a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes, and LLLT does not offer benefits.

CONCLUSIONS:   Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain.

KEYWORDS:   Acupuncture; Manual therapy; Neck pain and associated disorders; Passive physical modalities; Systematic review; Whiplash-associated disorders



From the Full-Text Article:

INTRODUCTION

Neck pain is a public health problem associated with disability, reduced health-related quality of life, and substantial health care system costs. [1–3] Numerous treatments, including manual therapies, passive physical modalities, and acupuncture, are commonly used to treat neck pain. [4, 5] However, few interventions have been demonstrated to be effective and most are associated with short-term benefits. [5]

Findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) In 2008, the Neck Pain Task Force synthesized evidence on the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) (Table 1). [5, 6]

For manual therapies, the Neck Pain Task Force [5] found that:

  • Manipulation and mobilization had similar effectiveness;

  • Manipulation and mobilization led to similar outcomes as other conservative interventions [exercise, low-level laser therapy (LLLT)] for subacute and chronic neck pain;

  • Western massage was equivalent to sham acupuncture but less effective than acupuncture for chronic neck pain; and

  • The risk of serious adverse events associated with manipulation was extremely low.


For passive physical modalities, the Neck Pain Task Force [5] found that:

  • LLLT was efficacious for short-term improvement of subacute or chronic neck pain;

  • Pulsed electromagnetic therapy was more effective than placebo;

  • Magnetic necklaces led to similar outcomes as placebo; and

  • Collars, transcutaneous electrical nerve stimulation (TENS), ultrasound, heat, and electrical muscle stimulation were equally or less effective than other interventions.

Finally, the Neck Pain Task Force reported that acupuncture may be effective for treating neck pain. [5]

The Neck Pain Task Force identified important gaps in the literature and outlined research priorities. These priorities included trials comparing cervical manipulation, thoracic manipulation, and traction for WAD and trials examining the effectiveness of conservative interventions for cervical radiculopathy. [7]

In 2008, the Neck Pain Task Force did not organize their findings according to the stages of development of interventions. The recent publication of the IDEAL framework, which classifies studies according to their stage of development, provides a useful framework to organize the evidence. [8, 9] Exploratory studies assess interventional efficacy, collect short-term outcomes, and prepare for designing evaluation studies. Exploratory studies do not provide evidence of effectiveness. In contrast, evaluation studies provide confidence in the intervention’s effectiveness or comparative effectiveness to a standard of care. [8, 9] Therefore, exploratory 1 studies do not provide evidence of effectiveness and need to be considered separately when synthesizing evidence in a systematic review. Moreover, the findings of exploratory studies need to be validated in evaluation studies.

The purpose of our systematic review was to update the findings of the Neck Pain Task Force [5] on the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD and NAD.



METHODS

      Registration

We registered our protocol with the International Prospective Register of Systematic Reviews (PROSPERO) in 2013 (CRD4201300XXXX, CRD4201300XXXX, CRD4201300XXXX, CRD4201300XXXX).

      Eligibility Criteria

Population:   Our review targeted studies of adults and children with WAD or NAD grades I-III, as previously classified by the Quebec Task Force and the Neck Pain Task Force, respectively (Table 2 - online). [10, 11] We excluded studies of neck pain due to major structural pathology (e.g., fractures, dislocations, spinal cord injury, infection, neoplasms, systemic disease).

Interventions:   We restricted our review to studies evaluating the specific effectiveness of manual therapies, passive physical modalities, or acupuncture (Table 3 – in text; Table 4 - online). We defined manual therapy (i.e., manipulation, mobilization, traction, and soft tissue therapy) as the application of hands-on and/or mechanically-assisted treatments. We defined a passive physical modality as a physical treatment (physico chemical or structural) involving a device that does not require active participation by the patient. Physico-chemical modalities have a common intention to treat using a thermal or electromagnetic effect. Structural modalities include non-functional assistive devices (to encourage a state of rest in anatomic positions) and functional assistive devices (to align, support, or indirectly facilitate function). We defined acupuncture as body needling, moxibustion, electroacupuncture, laser acupuncture, microsystem acupuncture (e.g., ear acupuncture), or acupressure (application of pressure at acupuncture points). [12]

Comparisons:   We included studies that compared manual therapies, passive physical modalities, or acupuncture to other interventions, waiting list (wait and see), placebo/sham intervention, or no intervention.

Outcomes:   Studies had to include one of the following outcomes to be elgigiSelf-rated or functional recovery, clinical outcomes (e.g., pain, disability), psychological symptoms, administrative outcomes, and/or adverse events.

Study characteristics:   Eligible studies met the following criteria: 1) English language; 2) randomized controlled trials (RCTs), cohort studies, case-control studies; and 3) an inception cohort of a minimum of 30 participants per treatment arm for RCTs or 100 subjects per exposed group for cohort studies or case-control studies. A sample size of 30 is conventionally considered the minimum needed for non-normal distributions to approximate the normal distribution. [12] The assumption that data is normally distributed is required to ascertain a difference in sample means between treatment arms. We excluded the following: 1) guidelines, narrative reviews, letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, guideline statements; 2) cross-sectional studies, case reports, case series, qualitative studies, non-systematic and systematic reviews, biomechanical studies, laboratory studies, studies not reporting on methodology; 3) cadaveric or animal studies; or 4) studies already included in the Neck Pain Task Force Report. [5]

      Information Sources

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from January 1, 2000 to: 1) March 21, 2013 for manipulation, mobilization, and traction; 2) February 27, 2014 for soft tissue therapy; 3) April 9, 2013 for passive physical modalities, and 4) January 31, 2013 for acupuncture. We developed four distinct search strategies with a health sciences librarian (Appendix IA, IB, IC, ID), which were reviewed by a second librarian using the Peer Review of Electronic Search Strategies (PRESS) Checklist. [14]

The search strategy was first developed in MEDLINE and subsequently adapted to the other bibliographic databases. The search terms included subject headings (e.g., MeSH for MEDLINE) specific to each database and free text words relevant to WAD or NAD (grades I-III), manual therapies, passive physical modalities, and acupuncture. We used EndNote X6 reference management software to create a database containing the search results. [15]

      Study Selection

We used a two-phase screening process to select eligible studies. In phase one screening, random pairs of independent reviewers screened citation titles and abstracts to determine the eligibility of studies. Phase one screening resulted in studies being classified as relevant, possibly relevant, or irrelevant. The same paired reviewers independently reviewed the manuscripts of possibly relevant studies in phase two screening to make a final determination of eligibility. Reviewers met to resolve disagreements and reach consensus on the eligibility of studies. We involved a third reviewer if consensus could not be reached.

      Assessment of Risk of Bias

Eligible studies were critically appraised by random pairs of independent, trained reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for RCTs, cohort studies, and case-control studies. [16] All reviewers were trained in the evaluation studies using the SIGN criteria. Consensus between paired reviewers was reached through discussion, with an independent third reviewer if necessary. Authors were contacted if additional information was needed. After critical appraisal, studies with a low risk of bias were included in our evidence synthesis.

The SIGN criteria were used to qualitatively evaluate the presence and impact of selection bias, information bias, and confounding on the results of a study. We did not use a quantitative score or a cutoff point to determine the internal validity of studies. [17] Rather, the SIGN criteria were used to assist reviewers in making an informed overall judgment on the internal validity of studies.

Specifically, we critically appraised the following methodological aspects of a study: 1) clarify of the research question; 2) randomization method; 3) concealment of treatment allocation; 4) blinding of treatment and outcomes; 5) similarity of baseline characteristics between/among treatment arms; 6) co-intervention contamination; 7) validity and reliability of outcome measures; 8) follow-up rates; 9) analysis according to intention to treat principles; and 10) comparability of results across study sites (where applicable). After critical appraisal, studies judged to have adequate internal validity were deemed scientifically admissible (i.e. without high risk of bias) and were included in our data (results, evidence) synthesis.

      Data Extraction and Synthesis of Results

The lead author extracted data from studies with a low risk of bias to build evidence tables and the data were independently checked by a second reviewer. Meta-analysis was not performed due to the heterogeneity of scientifically admissible studies with respect to patient populations, interventions, comparators, and outcomes. We performed a qualitative synthesis of findings from the studies with a low risk of bias to develop evidence statements using best evidence synthesis principles. [18]

We stratified our results by the type of disorder (i.e., WAD or NAD grades I-III) and duration [i.e., recent (<3 months), persistent (≥3 months), variable duration (study does not distinguish between recent and persistent)]. To facilitate translation of evidence into clinically relevant findings, we stratified studies according to the IDEAL framework (exploratory versus evaluation studies). [8, 9] Exploratory studies investigate the short term efficacy (1–2 days) of interventions provided in 1–2 sessions.

      Statistical Analyses

We computed the inter-rater reliability for the screening of articles using the kappa coefficient (κ) and 95% confidence intervals (CI). [19] We calculated the percentage agreement for classifying studies into low or high risk of bias following independent critical appraisal. To quantify the effectiveness of interventions, we used data from studies with a low risk of bias by computing the relative risk or difference in mean change and its 95% CI where this information was available. The computation of the 95% CI for the difference in mean change was based on the assumption that the pre and post-intervention outcomes were highly correlated (r=0.8). [20, 21]

We used standardized cut-off values to determine if clinically important changes were reached in each trial for common outcome measures. These include a between-group difference of 2/10 on the Numeric Rating Scale (NRS) [22], 10/100 mm on the Visual Analogue Scale (VAS) [23], and 5/50 on the Neck Disability Index (NDI). [23–25]

      Reporting

This systematic review was organized and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. [26]



RESULTS

      Study Selection

We screened 8551 citations (Figures IA, IB, IC, ID - online). Thirty-eight articles were critically appraised, of which 22 had a low risk of bias. [27–49]

The inter-rater agreement for screening of articles was: 1) k=0.94 (95% CI 0.90; 0.98) for manipulation, mobilization, and traction; 2) k=0.95 (95% CI 0.91, 0.99) for soft tissue therapy; 3) k=0.91 (95% CI 0.86, 0.97) for passive physical modalities; and 4) k=0.93 (95% CI 0.84, 1.00) for acupuncture. The percentage agreement for article admissibility during independent critical appraisal was 84.2% (32/38).

      Study Characteristics

All 22 studies with a low risk of bias were RCTs (Table 5 - online). [27–49] Of these, we categorized seven studies as exploratory studies [27, 37, 41, 50–53] and 15 as evaluation studies. [28–35, 43–49] Most studies (21/22) evaluated adults with NAD and one targeted adults with WAD. [46]

      Risk of Bias within Studies

All studies with a low risk of bias used clear research questions, appropriate randomization, valid and reliable outcome measures, and intention to treat analysis where applicable (Table 5 - online). Most studies adequately fulfilled the following criteria: proper allocation concealment (20/22), proper blinding procedures where possible (20/22), and similarity at baseline across groups (17/22). [27–49] The follow-up rate was above 75% in all but one study [31] (Table 5 - online).

The main methodological limitations of studies with a high risk of bias included: poor or unknown randomization methods, poor or unknown allocation concealment, clinically important differences in baseline characteristics with no statistical adjustment in the analysis, likely attrition bias, and no report of intention to treat analysis. [54–66] We contacted the authors of five RCTs for additional information but none responded.



      Summary of the Evidence Published After the Neck Pain Task Force Report

      Exploratory Studies (Table 6 - online)

WAD   We found no exploratory studies with a low risk of bias for the management of WAD.

Grades I-II NAD of Variable Duration   A single strain-counterstrain session is no more effective than sham strain-counterstrain in patients were neck pain of one month to five years duration. [27] Participants randomized to strain-counterstrain received passive neck positioning aimed to induce minimal-to-moderate muscle tension for 90 seconds. Sham strain-counterstrain involved digital pressure adjacent to the spinous process of C4 with 30 degrees of passive neck rotation for 90 seconds. There were no between-group differences in neck pain intensity (Neck Pain Disability Scale), intensity, cervical motion or self-perceived recovery. [27]

Recent-onset Grades I-II NAD   Thoracic manipulation is efficacious for the management of recent NAD I-II. [37, 38] Masaracchio et al. reported that patients who received two sessions of thoracic manipulation reported clinically important improvements in neck pain (NRS), disability (NDI), and self-rated recovery compared to those randomized to two sessions of cervical mobilization and home exercise. [37] Similarly, Cleland et al. found that individuals who received two thoracic manipulations had clinically important reductions in neck pain (NRS) and disability (NDI) compared to those treated with thoracic mobilization. [38]

Persistent Grades I-II NAD   The type of neck mobilization has little impact on the outcomes of patients with persistent NAD I-II. [39, 40] In patients with persistent unilateral neck pain, there were no differences in pain (VAS) or range of motion (ROM) immediately after one session of targeted cervical mobilization targeted to the symptomatic side compared to one session of non-targeted cervical mobilization. [39] Similarly, patients receiving central posterior-anterior cervical mobilization had statistically significant but not clinically mportant reductions in pain (VAS) compared to those receiving randomly-directed mobilization. [40] Moreover, there were no post-intervention differences in cervical ROM or global perceived recovery. [40]

The efficacy of spinal manipulation for the management of persistent NAD I-II is unclear. There were no clinically or statistically significant differences in pain intensity (NRS), disability (NDI), and ROM outcomes between administration of one mid-cervical and one cervico-thoracic manipulation, and a 7–day application of KinesioTape over the cervical extensors. [41] Finally, one session of upper thoracic manipulation and placebo thoracic manipulation (applied manipulative force to an open hand contact at the upper thoracic spine) provide similar outcomes for pain (VAS) in patients with persistent NAD I-II. [42]


      Evaluation Studies (Table 6 - online)

Grades I-II WAD of Variable Duration   A 6–week course of needle electroacupuncture or simulated electroacupuncture provides similar disability (NDI) and health-related quality of life (SF-36) outcomes for WAD grade I-II. [46] Needle electroacupuncture led to statistically but not clinically significant changes in pain intensity (VAS) at three and six months follow-up. [46] Electroacupuncture involved needle electroacupuncture at specific points while simulated electroacupuncture involved deactivated electroacupuncture on needled points 20–30 mm away from these specific points.

Recent-onset Grades I-II NAD   In comparing a course of neck manipulation and neck mobilization (four treatments over two weeks) for recent NAD I-II, there were no differences in pain (NRS), disability (NDI), and health-related quality of life (SF-12) immediately and up to 12 weeks post5 intervention for recent NAD I-II. [44]

A soft tissue therapy intervention combining ischemic compression, strain-counterstrain, and muscle energy technique is associated with statistically but not clinically significant differences in pain (VAS), disability (NDI), and lateral flexion compared to muscle energy technique alone. [28] One group received integrated neuromuscular inhibition technique (i.e., ischemic compression, strain-counterstrain, and muscle energy technique) to the upper trapezius while the other group received muscle energy technique alone to the upper trapezius.

Persistent Grades I-II NAD   The effectiveness of spinal manipulation may be dependent on the treatment modalities that are provided with manipulation. Adding cervical and thoracic manipulation to a high dose supervised exercise program provides no additional improvement in pain, disability (NDI), global perceived effect, range of motion, strength or satisfaction up to 52 weeks post-intervention in patients with persistent NAD I-II. [43] Cervical manipulation with traditional Chinese massage is superior to traditional Chinese massage (relaxation, provocative, and gentle massage techniques) alone in reducing neck pain intensity (NRS), but not neck pain-related disability immediately post-intervention in patients with persistent NAD I-II. [31]

Compared to a self-care book, Swedish and/or clinical massage with self-care advice is superior for reducing neck disability (NDI) and symptom bothersomeness (NRS) in the short-term and for reducing symptom bothersomeness in the long-term for patients with persistent neck pain. [29] The massage group received various Swedish and clinical massage techniques at the discretion of the practitioner with verbal self-care advice, while the control group received information on neck pain causes, associated symptoms, exercises, posture, and treatment options.

Cupping massage and progressive muscle relaxation lead to similar changes in pain (VAS), pain perception, disability (NDI), psychological outcomes and quality of life (SF-36) in patients with persistent NAD. [30] Participants randomized to cupping massage attended a one-hour workshop on the home-based cupping massage technique (using a cupping glass and massage oil). Progressive muscle relaxation involved one hour of instruction by a psychologist on home-based techniques to achieve deep muscle relaxation, relieve muscle tension, and improve general well-being. Both groups continued independent home care twice per week for 12 weeks.

LLLT is not effective in reducing pain (VAS) or disability (NDI) compared to an inactivated laser device for the management of persistent cervical myofascial pain syndrome. [32] Participants were randomized to receive LLLT to three trigger points bilaterally using either an active device (wavelength of 830–nm, frequency 1000 Hz, power output 58mW/cm2, dose 7J per point) or a device that was not activated.

TENS and a multimodal soft tissue therapy program (neuromuscular technique, post isometric stretching, spray and stretch, and strain-counterstrain) lead to similar changes in pain (VAS), disability (NDI), and health-related quality of life (SF-12) at one or six month follow-up for persistent NAD I-II. [33] Participants were randomized to: 1) TENS (80 Hz, ≤150μs pulse duration); or 2) multimodal therapy that included a neuromuscular technique, post-isometric stretching, spray and stretch, Jones technique (i.e., strain counterstrain). Both groups received a home program consisting of postural skills and exercises.

The evidence does not support the use of needle acupuncture for the management of persistent NAD I-II. Two studies found that traditional Chinese medicine acupuncture and sham-penetrating acupuncture (same procedure as the needle acupuncture group but needles were superficially inserted 1cm lateral to traditional acupuncture points) lead to similar outcomes. [47, 48] There were statistically significant but not clinically important differences in pain (VAS) and disability (Northwick Park Questionnaire) favouring traditional Chinese medicine acupuncture. [47, 48] Moreover, Western acupuncture provides statistically but not clinically significant improvements in pain (VAS), disability (NDI), and health-related quality of life (SF-36) compared to non penetrating placebo electroacupuncture for persistent NAD I-II. [49] Western acupuncture involved needling of locally tender and traditional points, while the placebo group received inactivated electrodes to acupuncture points.

Grade III NAD of Variable Duration   Adding intermittent cervical traction to a multimodal program of care (postural education, manipulation or mobilization, exercise and home exercise) provides no additional benefits in pain (NRS) or disability (NDI) compared to sham cervical traction with the same multimodal care up to four weeks follow-up for the management of NAD grade III. [45] Patients were treated an average of seven visits over an average of 4.2 weeks.

Recent-onset Grade III NAD   Participating in a graded strengthening exercise program or wearing a semi-rigid cervical collar for six weeks provide similar improvements in arm pain (VAS), neck pain (VAS), or disability (NDI) to patients with recent NAD III. [35] Both treatments were superior to advice. Participants were randomized to: 1) three weeks of wearing a semi hard cervical collar and prescribed rest followed by three weeks of weaning from the collar; 2) advice to continue daily activities; or 3) six weeks of supervised graded strengthening exercises for the neck and shoulder.

LLLT leads to statistically but not clinically significant improvements in arm pain, neck pain (VAS), disability (NDI), and physical health-related quality of life (SF-12) compared to placebo LLLT (deactivated laser treatment) for the management of recent NAD III. [34]


      Adverse Events

Sixteen of the 22 studies with a low risk of bias addressed the occurrence of adverse events [27, 29–31, 33, 34, 36–41, 43, 44, 48, 67, 68]. Most adverse events were mild to moderate and transient (Table 6 and Table 7). No serious neurovascular adverse events were reported. Most studies had a rate of minor adverse events ranging from zero to about 30% [33, 35–37, 39, 40, 42–48, 50]. One study [43] reported mild and transient adverse events in 98.9% of patients who received high dose strengthening exercise therapy and spinal manipulation, and 96.6% who received the same exercise therapy alone. Two serious adverse events in patients allocated to cervical mobilization were reported in one study, but were reported as unrelated to treatment by the attending medical specialists (one participant had a cardiac event and one developed severe arm pain and weakness three days after the mobilization session). [44]



DISCUSSION

Since 2008, the literature on the effectiveness of manual therapies, passive physical modalities, and acupuncture for neck pain has advanced. Our review adds to the existing knowledge base by clarifying the effectiveness of acupuncture, manipulation, mobilization, soft tissue therapies, LLLT, and taping for NAD grades I-II. There are recent studies with a low risk of bias investigating the effectiveness of a cervical collar, LLLT, and traction for the management of NAD grade III. Key findings from our synthesis of the evidence are outlined in Table 8.

      New Findings since the Publication of the Neck Pain Task Force Report

Exploratory studies:   Based on exploratory evidence, we found that thoracic manipulation provides benefit to individuals with recent NAD grades I-II, but is no better than placebo for treating persistent NAD grades I-II. We found that the type of neck mobilization may not impact the outcomes of patients. We also found that one session of cervical and cervico thoracic manipulation is as effective as one week of kinesiotape over the neck in the short-term for persistent NAD grades I-II. For soft tissue therapy, we found that strain counterstrain is not efficacious for NAD.

Exploratory studies:   We found that strain-counterstrain and ischemic compression provide no added benefit to muscle energy technique for recent NAD grades I-II. For persistent NAD grades I-II, we found that manipulation provides added benefit to traditional Chinese massage, but not to high-dose supervised exercises. We also found that home-based cupping massage leads to similar outcomes to home-based progressive muscle relaxation for persistent NAD grades I-II. However, it is important to note that the progressive muscle relaxation used in this study does not reflect how the intervention would be delivered in clinical practice. Specifically, the trial by Lauche et al. investigated progressive muscle relaxation performed by patients at home after they were instructed by a psychologist during a one hour session [30]. Finally, we found that LLLT was not effective for recent onset NAD grade III and traction does not provide added benefit to a multimodal program for NAD III.


      Results that are Consistent with Findings of the Neck Pain Task Force

Evaluation studies:   We found that cervical manipulation and cervical mobilization lead to similar outcomes in individuals with recent NAD grades I-II. We also found that there were no serious adverse events reported in randomized clinical trials on manipulation. We did not find any studies that compared different techniques of cervical manipulation; therefore, it is unclear if specific cervical manipulation techniques are more effective than others.


      Results that are not Consistent with Findings of the Neck Pain Task Force

Evaluation studies:   We found that relaxation and/or clinical massage added benefit to self-care advice when compared to self-care advice alone for persistent NAD grades I-II. In 2008, the Neck Pain Task Force reported that relaxation massage was not effective (equal to sham acupuncture) for chronic neck pain. While these results may appear contradictory, it is possible that the clinical (not relaxation) massage provides benefit to patients with persistent neck pain.

We found new evidence suggesting that LLLT is not effective for persistent NAD grades I-II. However, when combining the new evidence with Neck Pain Task Force findings from five studies [69–73], the preponderance of evidence suggests that clinic-based LLLT is effective for persistent NAD.

We found that for NAD grade III, graded strengthening exercises and cervical collar with rest were equally effective. However, caution should be taken when considering the use of cervical collars because of the potential for iatrogenic disability [13, 74, 75]

For acupuncture, we found that electroacupuncture is not effective for WAD I-II, while Western acupuncture and needle acupuncture is not effective for persistent NAD I-II. These new findings contradict the evidence available to the Neck Pain Task Force [75], which found that needle acupuncture, when added to routine general medical care, may provide short-term benefits to patients with persistent neck pain. [68] However, the Neck Pain Task Force warned that this result may be attributed to favourable patients’ expectations, since all participants in this study were patients of physicians who practice acupuncture. [75] Overall, the updated evidence suggests that acupuncture may not be effective for the management of recent or persistent neck pain. It is important to note that acupuncture was compared to needling interventions where skin was penetrated, which may have a physiological effect; studies with non-penetrating sham/placebo interventions are needed.


      Findings of the Neck Pain Task Force that We Cannot Support or Clarify

We did not find new evidence on the effectiveness of ultrasound, diathermy, heat therapy, electrical muscle stimulation, or magnetic necklaces. The Neck Pain Task Force found that TENS provides no clinically important benefit compared to placebo. [75, 76] Our review found new evidence that TENS provides similar outcomes to a multimodal program of care focused on soft tissue therapy. However, as the effectiveness of this multimodal program of care is unknown, this new evidence cannot be used to support or refute the findings of the Neck Pain Task Force. Overall, there is a lack of evidence supporting the effectiveness of TENS in this population.

Unlike previous systematic reviews, we stratified admissible studies into exploratory (efficacy) and evaluation (comparative effectiveness) according to the IDEAL framework to facilitate the clinical interpretability of results. [8, 9] Exploratory studies are used to develop well-informed hypotheses about the effectiveness of promising interventions that need to be tested in evaluation studies. Our review differentiates studies by the nature of their design for the purpose of contextualizing the dose and duration of outcomes to reflect clinical practice. It is important for clinicians, policy makers, and patients to place more emphasis on the results of the evaluation studies, since they provide confidence in the intervention’s effectiveness or comparative effectiveness to a standard of care. There should be caution in including results from exploratory studies into clinical guidelines or practice pending more robust evaluation studies.

Strengths and Limitations

There are strengths to our review. We conducted a rigorous search of the literature and the search strategy was peer reviewed. We used clear case definitions, inclusion criteria, and exclusion criteria for the selection of studies and only considered studies with adequate sample sizes. We used the SIGN criteria to standardize the critical appraisal process. [19] Lastly, our conclusions were based on the best evidence synthesis method to minimize the risk of bias associated with using low quality studies. [20] A best evidence synthesis is considered an appropriate alternative to a meta analysis when heterogeneity exists across patient populations, interventions, comparisons, and outcomes. [20]

Our review also has limitations. We only searched the English literature, which may have excluded some relevant studies, but this is an unlikely source of bias. [77–81] Qualitative studies that explored the lived experience of patients were not included. Thus, this review cannot comment on how patients valued and experienced their exposure to manual therapies, passive physical modalities, or acupuncture.



CONCLUSIONS

Since 2008, there is new scientific evidence on the effectiveness of manual therapies, passive physical modalities, and acupuncture informing their use for the management of neck pain. Our update of the Neck Pain Task Force suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and other passive physical modalities (heat, cold, diathermy, hydrotherapy, ultrasound) are not effective and should not be used to manage neck pain.


Acknowledgement

This study was funded by the Ontario Ministry of Finance and the Financial Services Commission of Ontario (RFP No.: OSS_00267175). This research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Dr. Pierre Côté, Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology. The funding agencies were not involved in the collection of data, data analysis, interpretation of the data, or drafting of the manuscript. The authors acknowledge the invaluable contributions to this review from: Angela Verven, J. David Cassidy, Doug Gross, Gail Lindsay, John Stapleton, Michel Lacerte, Mike Paulden, Murray Krahn, Patrick Loisel, Poonam Cardoso, Richard Bohay, Roger Salhany, and Shawn Marshall. The authors also thank Trish Johns-Wilson at the University of Ontario Institute of Technology for her review of the search strategy.



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